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B-20-656 - 0008 AUBURN ROAD - Building Permit V qM G� l The Commonwealth of Massachusetts CITY OF fl Board of Building Regulations and Standards .SALEM Massachusetts State Building Code,780 CMR Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling n This Section For Official Use Only 1 Building Permit Number: Date Applied: Building Official(Print Name) Signature —Date ' N t SECTION 1:SITE INFORMATIO K 1.1 Property Address: - 1.2 Assessors Map &Parcel Numbers 8� V,0- 1.1a Is this an accepted street?yes no Map Number Parcel Number. 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) ." Front Yard Side Yards"- Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes[] SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Recor : Name(Prim City,State,ZIP AUJovf.-► led 1 (7L5.1 b3 IIo.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED'WORK2(check all that apply)- New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Propos Work2: I A1 -±oN1;-'C rO.ev^ e�6 -- t`1 C o yC F e X ZO on CoP1 re e- JUL 7 N08:5 7 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use.Only (Labor and Materials) 1.Building $ / 0 p p O 1. Building Permit Fee: $ Indicate how fee is determined: ❑tStandatd.Ciiy/T WnAppli6atibji:e' 2.Electrical $ d b ❑Total Project Cose(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ 1 O o Check No. Check Amount: . Cash Amount: 6. Total Project Cost: $ / ❑Paid in Full ❑Outstanding Balance Due: `71 g Iq va U _C_ R SECTION 5: CONSTRVCTION.SERVICES ' 5.1 Construction Supervisor License(CSL) - /o 2 p Jef _r-A.A. ('.�.--� License Number Expiration Date Name of CSL older V �? List CSL Type(see below) No.and Street Type Description ©_l 4 7 0 U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofnig Covering WS -Window and'S'idin � SF Solid Fuel Burning Appliances r l 3 7 r A,,Lr,J of e,("'P 4,4 1 0 I Insulation Telephone Email address D Demolition 5.2 Regist ed Home improvement Contractor(HIC) L­V^� HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town, State,ZIP Telephone SECTION 6;WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.`§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes ....... No........... ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work autho4d y this b '! u permit application.. ,�C-:-- -r- (�->10)AJ A '�J,� t-- • - 7� 7 �La Print Owner's Name(Electronic Signature) Date 'SECTION 7b:,OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this applic n is true and accurate to the best of my,knowledge and understanding. Print O or Autho ' d gent's Name(Electronic Signature) " "'- _ - ",t \ Date NOTES: 1. An wner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program orguaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.maa.ggv/oca v�Information on the Construction Supervisor License can be found at www.mass.goy/dgs 2. When substantial work is planned,provide the information below: r Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths _y Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost"- ,j The Commonwealth of Massachusetts Department of Industrid Accidents I Congress Street,Suite 100 Boston,MA 02114 2017 ' wwwsmassgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Elecfticians/Plumbers. TO BE FILED WI m mm PERNaT1'mG Aurkowy. Ar►nllcant Information Please Print Legibly -Name(Business/Organaedonnndividaaly r.P na,r ram,, C4 r' L L Address:• 2 A v r City/Steraip: (54 vv_ k4 A d►ctV Phone#: c 7-7 2- An you,an employer?Check the appropriate box: Type Of project(required): _ 1.❑I aura employer with 7 employees(tW andvorpare-time).' 7. New construction any am a sale proprietor or pettpar Wp and have no employee'working for in S. Remodeling • arry eapanity.[No wotlmrs'comp.insurance rtxlu,itad] ^ 3. Tam a homeowner loin all urork i£ ]t ' p• Demolition ❑ g myself[No wo dws'comp.insurance required.] w '4.❑I am a homeowner and will ire hiring conttwctors to conduct so worknn mylsoper►y. 1 wn11 10 0 Building addition emtue that all colt tams adwhave wadoeis'compet»ation ins or am sole 110 Electrical repairs or additions 1FROP"i 1— wsb no employees. - 12.Q Plumbing repairs or additions 5.❑l am a geneeal cotdtactor and I have hired the Noted on'the h� 13.Q Roof repairs sub-coturectms have employees and have wor1mW comp.itmaAoe t 6.0 We ate a corporedon end its ofters have exercised their right ofesemptim per MOO c. 14.❑Othei 152.¢1(41 and we have no employees.[No workms'comp.insurance Yquited.] *Any appliemt that checks box#1 mtst.atso fW out the section below showigg their Woft a'eonvenssdon policy infottm H— t Nomeownas who submit this affidavit indicating they ate dobi all wink and then him=Mate emareetonmust submit a new attid"adkatutg such. kont mamma Burt check this box must amtclmd an additional sheet abowbrg this none of the sub-coz�and state whether or not those entities have employees. if the sub-contractors have employees,they trust provide thaw workus'comp.policy number. I era an eniptoyer diNis provl&ig workers'compensadon fn umce for nr employs= Below is dre polleyand job site tnformadon. (� Insurance Company Name:_ b u o� Policy#or Self-ins.Lic.#• _ R 4'J G 1 �'q 0 3 Expiration Date: Job Site Address: City/SwAip: Attach a copy of the workers'compensation policy dedaration page(showing the policy number and expiration date). Failure to secure coverage as required under M©L c. 152,§25A is a criminal violaticnT.i*ishable by a fine up to$1,500.00 ;Ltlw and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a One of up to$250.00 a day against the violator.A copy of this statement may be forwarder to the Office of Investigations of the DIA for insurance coverage verification. Ida hereby c&rWy under pains andpenaldes ofpedwy that the Wennadon provided above 6 true and correct ,Signature' Dom. Phone#• b- 31? b C, 'pZ - - Offmial we only. Do not wrik in dds arv%0 be completed by ciy or town o i*L !, City or Town:_ Pwmit/License# Issuing Authority(circle one): 1.Board of Health 2:Building Department 3.CitylTown Clerk kElectritml Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 1', {� r! AS ^ E I b 7� � s u-; 177 I► L/I. }� ..,_..-...s_. .�-..---.,,. -,..-..s+w,�..... e..�.w�,..,or+s....�....w.a..,w:�.+s.,....,.-...wr,,,«.•.......W - ,�.�..�...*xw.w.�.I X I ,\ y I �.�� v � �+.rye .. a � .m�� �•. �. gym.. -t' v� � a � V ji7j 1 I{. 1 i V CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 98 WASHINGTON STREET,2ND FLOOR TEL:978-745-9595 MMERLEY DRISCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER Construction Debris Disposal Affidavit (requiredfor all demolition & renovation work) In accordance with the sixth edition of the State Building Code,780 CMR,Section 111.5 Debris, and the provisions of MGL c40,554; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licenses waste deposit facility as defined by MGL c 211,S150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Sin r of pplicant (today's date) .ate l